America First, African Health
Tracking the U.S. bilateral health agreements reshaping health systems across sub-Saharan Africa — and the controversies they have ignited.
In roughly six weeks at the end of 2025, the United States quietly rewrote the rules of global health diplomacy. Under the banner of the America First Global Health Strategy, the Trump administration signed a series of bilateral Memorandums of Understanding (MOUs) with more than a dozen African governments, committing billions of dollars in health assistance and demanding billions more in contributions from partner countries.
At the beginning of 2026, at least 14 African nations had signed on: Nigeria, Cameroon, Côte d'Ivoire, Kenya, Uganda, Ethiopia, Malawi, Botswana, Liberia, Eswatini, Lesotho, Mozambique, Madagascar, Sierra Leone, and Rwanda. This article analyzes those agreements and why they have ignited fierce debate from Nairobi to Geneva.
The Strategy Behind the Strategy
On September 18, 2025, the State Department released its 36-page America First Global Health Strategy, a document that, by its very name, signals a fundamental shift in how Washington frames its role in global health. Gone is the language of humanitarian obligation. In its place is a frank acknowledgment that U.S. global health funding is "a strategic mechanism to further our bilateral interests around the world."
Prevent infectious disease outbreaks from reaching U.S. shores by strengthening surveillance, laboratory networks, and outbreak response capacity in partner countries.
Build durable, nationally-owned foreign health systems that reduce future aid dependency and deepen bilateral strategic relationships with partner governments.
Promote U.S. health innovations, pharmaceutical products, and private-sector commercial partnerships abroad, opening new markets for American companies.
2025
2025
2025
2025
2025
2025
2025
2026
The strategy was also a direct response to the dismantling of USAID earlier in 2025. With the traditional machinery of U.S. foreign assistance broken down and annual global health spending cut by nearly 70%, the MOUs represent the administration's attempt to rebuild engagement on entirely new terms, routing funding directly through partner governments rather than NGOs and implementing partners.
Country-by-Country: The Agreements
Each MOU pairs a five-year U.S. funding commitment with a negotiated pledge from the partner government to increase domestic health spending. Below are key details for each signed agreement, with bars showing the split between U.S. contribution (blue) and partner co-investment (green).
Five-Year Bilateral Health Agreement Values by Country
Sources: U.S. Department of State press releases (Dec. 2025 – Jan. 2026); KFF Tracker: America First MOU Bilateral Global Health Agreements (updated Feb. 2026).
Who Pays How Much? Funding Split by MOU
Co-investment % for Mozambique estimated from ~30% increase in domestic health expenditure over FY24 baseline (World Bank Health Expenditure data).
The Central Controversy: Are These Cuts in Disguise?
The headline figures — $5.1B for Nigeria, $2.5B for Kenya, $2.3B for Uganda — read as historic commitments. But the Center for Global Development's analysis tells a more complicated story.
"These compacts represent a reduction in total U.S. health spending for each country. Relative to FY24 health obligations, the agreements amount to a 49 percent decrease, on average, in annual U.S. financial support."
The explanation lies in how the MOUs are structured over five years. While first-year funding may appear comparable to recent levels, the trajectory is consistently downward. By Year 5, in most agreements, the expectation is that the country will have absorbed the bulk of costs — and U.S. support will have wound down dramatically. The "total MOU value" numbers include both U.S. and partner contributions added together, making the total appear large even as the U.S. portion shrinks.
MOU Commitments vs. Historical FY24 Baseline
Methodology: Annual U.S. contribution under MOU (total U.S. commitment ÷ 5 years) compared to FY2024 U.S. health obligations for each country. Asterisked values are estimates based on partial disclosure.
Architecture of the New Approach
From NGOs to Governments
The most structurally significant shift is the move away from the traditional model, in which U.S. health assistance flowed through international NGOs, implementing partners, and contractors. The new approach routes funding directly to partner governments, which are expected to manage and disburse it through their national systems.
The Co-Investment Requirement
Every MOU requires the partner country to increase its domestic health spending alongside and ultimately beyond the U.S. contribution. This is framed as "shared responsibility" and moving countries toward "durable, self-reliant health systems." The logic is that aid dependency is ultimately harmful, and partner governments must have skin in the game.
The enforcement mechanisms vary. Uganda's MOU contains one of the most explicit triggers: a 2:1 funding reduction clause; if Uganda misses its annual domestic spending commitments, the U.S. is entitled to reduce its own contribution by double the shortfall. Many other MOUs leave the consequences of non-compliance vague, deferring specifics to an implementation-phase annex.
Private Sector and "America First" Commercial Goals
The Rwanda MOU makes explicit what others imply: U.S. companies are expected to benefit. Ginkgo Bioworks received a $10 million allocation for biothreat surveillance; Zipline's drone delivery infrastructure is integrated into Rwanda's health logistics. The Côte d'Ivoire MOU explicitly states it "expands opportunities for U.S. companies by supporting modern logistics, data, and supply-chain solutions." This is one of the strategy's four distinguishing features; a frank acknowledgment that global health serves commercial as well as humanitarian ends.
Data Sovereignty and the Kenya Court Case
A consistent thread running through the MOUs is an emphasis on data systems and disease surveillance infrastructure integrated into national health information systems — but that also ensure the U.S. can "monitor outbreaks and health outcomes well into the future." Civil society organizations have raised pointed questions about who controls this data and on what terms U.S. authorities may access it.
In Kenya, those concerns crystallized into a legal challenge within days of the December 4 signing. A Kenyan court ordered the suspension of the framework's implementation, citing concerns about data security and the agreement's implications for Kenyan citizens' personal medical records. More than 50 civil society organizations, coordinated by the People's Health Movement, published an open appeal urging African governments not to sign, warning that the agreements could effectively transfer sensitive patient records to U.S. oversight.
The Geopolitics: China, Pan-Africa, and the Pandemic Agreement
“What is defended domestically as pragmatic bilateralism is, in aggregate, eroding the credibility of Africa’s health sovereignty agenda.”
The America First strategy explicitly, if understatedly, targets China's growing influence in African health systems. The bilateral structure of the agreements also serves a geopolitical function: locking in individual country relationships prevents the bloc-level bargaining that has allowed African nations to push for more equitable terms in multilateral forums.
This brings us to perhaps the most consequential long-term concern: the effect on African collective bargaining power. At precisely the moment African countries are signing bilateral health agreements with the U.S., negotiations on the global Pandemic Agreement and its Pathogen Access and Benefit Sharing (PABS) system remain incomplete. A 47-state African group has been pushing for genuinely equitable distribution of medical resources developed using shared pathogen data. Bilateral pathogen-sharing agreements with the U.S., embedded in some MOUs, risk fragmenting that negotiating bloc.
The August 2025 Africa Health Sovereignty Summit and the subsequent Accra Reset initiative at the UN General Assembly represented a genuine momentum toward a reconfigured global health order anchored in African leadership. Critics of the MOU framework argue that bilateral deals, even large, well-funded ones, chip away at that agenda by pulling individual governments out of the solidarity coalition with immediate cash.
What Remains Unknown
Despite the volume of press releases and headline figures, major questions remain unanswered heading into the April 2026 implementation deadline:
| Uncertainty | Status |
|---|---|
| Verification of co-investment — How will domestic spending pledges be measured and enforced? | Deferred to implementation-phase annex in most MOUs |
| Congressional appropriations — Are the funding commitments backed by actual budget law? | Subject to annual appropriations; no multi-year guarantee |
| Transition gaps — What happens to USAID-funded NGO programs winding down before government systems are ready? | Largely unaddressed; a key concern of CGDev and KFF |
| Data governance — On what legal terms can U.S. authorities access surveillance data? | Active litigation in Kenya; unresolved elsewhere |
| Major unsigned countries — South Africa, Tanzania, DRC, Zambia | Negotiations ongoing; South Africa's role in G20 adds complexity |
| Procurement transition — State Dept. has never managed large-scale commodity procurement before | Partial model: U.S.–Global Fund–Gilead lenacapavir arrangement as one potential path |
Conclusion
The America First Global Health Strategy's bilateral MOU framework represents the most significant restructuring of U.S. global health engagement in a generation. In roughly six weeks, Washington committed more than $13 billion in health assistance across more than a dozen African nations — while simultaneously requiring those nations to commit billions of their own.
There is genuine substance in the new approach. Moving toward government-led, nationally owned health systems is a goal that African health ministers, the African Union, and independent analysts have long championed. Front-loading funding, setting specific measurable targets, and demanding domestic co-investment are not, in principle, bad ideas.
But the speed of execution, the reduction in aggregate funding relative to historical baselines, the data sovereignty concerns, the fragmentation of Pan-African solidarity, and the frank subordination of humanitarian goals to U.S. strategic interests all warrant serious, ongoing scrutiny.
The agreements are signed. Implementation begins in April 2026. What happens next — in Nairobi's courtrooms, in Abuja's health ministries, in Geneva's Pandemic Agreement negotiations, and in the communities where HIV, malaria, and tuberculosis remain daily realities — will determine whether this framework delivers on its stated promise or deepens the vulnerabilities it claims to address.
